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Post- Caregiver-GAP Funding Survey
1.
Who provided the service you requested?
2.
Have you felt a reduction in caregiving stress because of having Caregiver-GAP funds?
Yes
No
Please explain.
3.
Regarding the use of Caregiver GAP funds, do you feel …? (Check all that apply)
More comfortable accepting help from others
That I should have used GAP support earlier
Other (Please Describe)
4.
Has the use of GAP funding made a positive difference to you and your family?
Yes
No
5.
If given the opportunity, would you use Caregiver GAP services again?
Yes
No
6.
I feel …. (Check all that apply)
More confident about asking for help or assistance with care of my loved one
More balance in my life in giving care and also trying to take care of myself
I have regained some enjoyable activities I had lost in caregiving
I am able to continue in my caregiving role for the foreseeable future
7.
BEFORE receiving Caregiver GAP funds, how “stressed” were you as a result of caring for your family member?
Low Stress
Moderate Stress
Very Stressed
8.
NOW that you have received Caregiver GAP funds, how “stressed” are you as a result of caring for your family member?
Low Stress
Moderate Stress
Very Stressed
9.
Do you have someone you can call on in an emergency to fill in for you as a caregiver?
Yes
No
10.
Please indicate your overall level of satisfaction with the Caregiver GAP funding you recently received
Completely Dissatisfied
Moderately Dissatisfied
Moderately Satisfied
Completely Satisfied
11.
Is there anything else that would help you in your caregiver role? Please explain:
12.
What is your 5 digit Zip Code
13.
Age Category
under 60
60 - 64
65 - 74
75 - 84
85+
14.
Gender
Femal
Male
Female to Male / Transgender Male
Male to Female / Transgender Female
Decline to Answer
Other (please specify)
15.
Ethnicity
Not Hispanic or Latino
Hispanic or Latino
16.
Your Race
American Indian or Alaska Native
Asian or Asian American
Black or African American
Hispanic or Latino
Middle Eastern or North African
Native Hawaiian or other Pacific Islander
White
Another race
17.
What is your relationship with the person receiving care?
Wife
Husband
Domestic Partner, including Civil Union
Daughter / Daughter-in-Law
Son / Son-in-Law
Sister
Brother
Grandmother
Grandfather
Mother
Father
Other Relative
Non-Relative
